Download Intracranial Saccular Aneurysms

Numa Perez, MSIII
Gillian Lieberman, MD
INTRACRANIAL
SACCULAR ANEURYSMS
CASE BASED STUDY OF COMPLICATIONS AND
NOVEL WAYS OF MANAGEMENT
Numa Perez, Harvard Medical School, Year III
Gillian Lieberman, MD
AGENDA
1. Patient
2. Intracranial Saccular Aneurysms
1.
2.
3.
4.
5.
Epidemiology
Location
Risk Factors
Management
Rupture
1.
2.
3.
4.
Manifestations
Diagnosis
Complications
Management: Traditional and Novel Approaches
3. Subarachnoid Hemorrhage
4. Back to patient
2
Numa Perez, MSIII
Gillian Lieberman, MD
OUR PATIENT: HISTORY
• Mr. X is a 46 yo M found down in the kitchen by his
son. He was in his usual state of good health until
~10 days ago, when he began to experience
worsening headaches that he attributed to
migraines. This morning, his son heard a loud thud in
the kitchen. He found his father unconscious and
unresponsive.
3
Numa Perez, MSIII
Gillian Lieberman, MD
OUR PATIENT: PRESENTATION
• Physical Exam:
• Neurological Status:
• Hunt and Hess grade: 5
• Glasgow Coma score: 3
4
Numa Perez, MSIII
Gillian Lieberman, MD
NEUROLOGICAL STATUS:
HUNT AND HESS
5
Numa Perez, MSIII
Gillian Lieberman, MD
NEUROLOGICAL STATUS:
GLASGOW COMA SCALE
6
Numa Perez, MSIII
Gillian Lieberman, MD
OUR PATIENT: INITIAL EVALUATION
• Imaging:
1.
CT:
1.
2.
2.
CCTA
Xray Angiography
7
Numa Perez, MSIII
Gillian Lieberman, MD
OUR PATIENT:
NON-CONTRAST
CT
Findings:
1. Blood within sulci
2. Normal hypodense
appearance of sulci
BIDMC PACS
8
Numa Perez, MSIII
Gillian Lieberman, MD
OUR PATIENT:
NON-CONTRAST
CT
Findings:
1. Blood within sulci
2. Blood settling
dependently in the
posterior horn of
lateral ventricles
BIDMC PACS
9
Numa Perez, MSIII
Gillian Lieberman, MD
OUR PATIENT:
NON-CONTRAST
CT, cont’d
Findings:
1. Large collection of
blood in the
suprasellar cistern
2. Blood in the
circummensencephalic cistern
3. Blood in the
quadrigeminal cistern
BIDMC PACS
10
Numa Perez, MSIII
Gillian Lieberman, MD
CEREBRAL
CISTERNS:
Normal aspect on
NCHCT
http://nypemergency.org/reading_emergency_images/head_ct.html
11
Numa Perez, MSIII
Gillian Lieberman, MD
OUR PATIENT:
CT ANGIO
Giant 2.4 x 1.9 cm
aneurysm arising from
the right ICA at the
origin of the right
PCOM. There is no
associated hyperdense
"jet" to suggest active
extravasation.
BIDMC PACS
12
Numa Perez, MSIII
Gillian Lieberman, MD
OUR PATIENT:
X-RAY ANGIO
19 x 18mm posteriorly
directed right
communicating
segment ICA aneurysm
with a 6mm neck.
BIDMC PACS
13
Numa Perez, MSIII
Gillian Lieberman, MD
OUR PATIENT: DIAGNOSIS
• Subarachnoid Hemorrhage (SAH) due to ruptured
Intracranial Saccular Aneurysm (ISA) of the Internal
Carotid Artery (ICA) at the bifurcation of the
Posterior Communicating Artery (PCOM)
14
Numa Perez, MSIII
Gillian Lieberman, MD
ANATOMY: ORIGIN OF PCOM
http://medicalterms.info/anatomy/External-Carotid-Arteries/
15
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: EPIDEMIOLOGY
• Meta-analysis, 83 study populations, 21 countries,
1450 UIAs, 94,912 patients:
•
•
•
•
3.2% in those w/o comorbidity
3.4% in those w/ FH of intracranial aneurysm or SAH
6.9% in those w/ ADPKD
1.61 PR for women comp. to men
Vlak M.H. et al. Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity,
country, and time period: a systematic review and meta-analysis. The Lancet Neurology, 2011; 10: 626-636
16
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: LOCATION
• 85% are in anterior circulation, predominantly Circle
of Willis:
• Junction of the ACOM and ACA ~30%
• Junction of the PCOM and ICA ~25%
• Bifurcation of MCA ~20%
Brisman J.L. et al. (2012, July). Neurosurgery for Cerebral Aneurysm. Medscape. Retrieved from
http://emedicine.medscape.com/article/252142-overview
17
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: LOCATION, cont’d
http://emedicine.medscape.com/article/252142-overview
18
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: RISK FACTORS
1. Genetics:
• Ehlers-Danlos and Pseudoxanthoma Elasticum (but not Marfan)
• Autosomal Dominant Polycystic Kidney Disease (ADPKD)
• Familial Aldosteronism type I (Glucose-Remediable Aldosteronism,
?linked to chronic hypertension)
2. Family History (9.1%
by ADPKD)*
in individuals >30, not necessarily accounted for
* Ronkainen A. et al. Familial intracranial aneurysms. Lancet, 1997; 349(9040): 380-384
19
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: RISK FACTORS, cont’d
3. Cigarette smoking
• 3 and 4.7 RR for men and women respectively
4. Hypertension
5. Estrogen deficiency (estrogen deficiency of menopause causes a
reduction in the collagen content of tissues)
6. Coarctation of Aorta
20
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: SCREENING RECOMMENDATIONS
1. >2 first degree relatives w/ SAH:
a. Yearly for 3 years
b. Every 5 years for those w/ no aneurysms on initial 3 scans
2. ADPKD, plus one of the following:
•
•
•
previous rupture
positive family history
warning symptoms
•
•
high-risk occupation
prior to surgery that is likely to
be associated with
hemodynamic instability
a. Yearly for 2-3 years
b. Every 2-5 years thereafter if the aneurysm is clinically and
radiographically stable
21
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: NATURAL HISTORY
• International Study of Unruptured Intracranial
Aneurysms (ISUIA):
• Centres in the USA, Canada, and Europe enrolled patients
for prospective assessment of unruptured aneurysms.
• Investigators recorded the natural history in patients who
did not have surgery, and assessed morbidity and mortality
associated with repair of unruptured aneurysms by either
open surgery or endovascular procedures.
Wiebers D.O. et al. Unruptured intracranial aneurysms: natural history, clinical outcome,
and risks of surgical and endovascular treatment. Lancet, 2003; 362(9378):103
22
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: NATURAL HISTORY
ISUIA findings:
• Size, site, and risk of rupture:
• 5-year rates of rupture for aneurysms in the Anterior and
Posterior circulation respectively:
• 7-12mm: 2.6%, 14.5%
• 13-24mm: 14.5%, 18.4%
• >25mm: 40%, 50%
Wiebers D.O. et al. Unruptured intracranial aneurysms: natural history, clinical outcome,
and risks of surgical and endovascular treatment. Lancet, 2003; 362(9378):103
23
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: MANIFESTATIONS
• Most asymptomatic unless ruptured, leading to SAH
• Some may present w/ symptoms:
• Headache (severity comparable to SAH; many times
misdiagnosed as migraine)
• CN III palsy
• Ischemia from embolus developed at site
24
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: DIAGNOSIS
• MRA: 1
• 3D time-of-flight MRA w/ volume rendering at 3.0 Tesla
• 99% sensitivity and 97% specificity for aneurysm size < 3 mm
to > 10 mm
• CTA: 2
• Single-detector up to 64-detector CT
• 97.2% sensitivity and 97.9% specificity for aneurysms >4mm,
regardless of number of CT detectors
• 94% sensitivity for aneurysms <4mm w/ 64-detector CT
1.
2.
Yi, M.H. et al. Contrast-free MRA at 3.0 T for the detection of intracranial aneurysms. Neurology, 2011; 77(7): 667-676
Menke, J. et al. Diagnosing cerebral aneurysms by computed tomographic angiography: meta-analysis. Annals of Neurology, 2011; 69: 646-654
25
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: MANAGEMENT PRIOR TO RUPTURE
1. Expectant management
2. Surgical approach
3. Endovascular approach
26
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: EXPECTANT MANAGEMENT
• CTA or MRA annually for two to three years, and
every two to five years thereafter if the aneurysm is
clinically and radiographically stable
• Avoid:
•
•
•
•
•
Smoking
Heavy alcohol
Stimulant medications
Illicit drugs
Excessive straining and Valsalva maneuvers
Wiebers D.O. et al. Pathogenesis, Natural History, and Treatment of Unruptured
Intracranial Aneurysms. Mayo Clinic Proceedings, 2004; 79[12]: 1572-1583
27
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: SURGICAL MANAGEMENT
• Technique:
• Surgical clipping
• Outcomes:
• Surgery-related death or poor neurologic outcome was
13.7% at 30 days and 12.6% at one year. *
* Wiebers D.O. et al. Unruptured intracranial aneurysms: natural history, clinical
outcome, and risks of surgical and endovascular treatment. Lancet, 2003; 362(9378):103
28
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: SURGICAL MANAGEMENT
http://www.mizuho.com/sugita-titanium-2-aneurysm-clips-and-appliers
http://www.massgeneral.org/conditions/condition.aspx?id=87
29
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: ENDOVASCULAR MANAGEMENT
• Options
1. Traditional approaches:
1.
2.
Coil embolization
Liquid embolization
2. Novel approach:
1.
Flow diversion
3. Combination of both
• Outcomes:
• Therapy-related death or poor neurologic outcomes was
9.3% at 30 days and 9.8% at one year. *
* Wiebers D.O. et al. Unruptured intracranial aneurysms: natural history, clinical
outcome, and risks of surgical and endovascular treatment. Lancet, 2003; 362(9378):103
30
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: ENDOVASCULAR MANAGEMENT
COIL EMBOLIZATION
http://www.massgeneral.org/conditions/condition.aspx?id=87
http://www.ev3.net/assets/005/5513_w600h.jpg
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Numa Perez, MSIII
Gillian Lieberman, MD
ISA: ENDOVASCULAR MANAGEMENT
LIQUID EMBOLIZATION
http://www.ev3.net/assets/005/5493_w600h.jpg
http://www.ev3.net/assets/005/5494_w600h.jpg
32
http://www.ev3.net/assets/005/5495_w600h.jpg
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: ENDOVASCULAR MANAGEMENT,
FLOW DIVERSION, A NOVEL APPROACH
Pipeline Embolization Device (PED)
http://www.ev3.net/assets/006/5656.jpg
33
Numa Perez, MSIII
Gillian Lieberman, MD
PED: PRODUCT ANIMATION
http://www.youtube.com/watch?v=W6njop9QjAQ
34
Numa Perez, MSIII
Gillian Lieberman, MD
PED: THE BASICS
• Received FDA approval on April 6, 2011 for the
endovascular treatment of adults (> 22 yo) with
large or giant wide-necked intracranial aneurysms
of the ICA from the petrous to superior hypophyseal
segments.
• Made of 48 braided strands of woven wire mesh
containing 25% platinum and 75% cobalt–nickel
alloy.
Ferrel, A.S. et al. Developments on the horizon in the treatment of neurovascular
problems. Surgical Neurology International, 2013; 4:s31-7
35
Numa Perez, MSIII
Gillian Lieberman, MD
PED: THE BASICS, cont’d
• When fully expanded it provides approximately 3035% metal surface area coverage, significantly
more than that seen with other currently marketed
stents for use in the intracranial circulation. 1
• Its high density of coverage is designed to alter flow
and, even without intrasaccular coils, induce
aneurysm occlusion. 2
1.
2.
Ferrel, A.S. et al. Developments on the horizon in the treatment of neurovascular problems. Surgical Neurology International, 2013; 4:s31-7
Kallmes, D.F. et al. A New Endoluminal, Flow-Disrupting Device for Treatment of Saccular Aneurysms. Stroke, 2007; 38: 2346-2352
36
Numa Perez, MSIII
Gillian Lieberman, MD
PED: THE BASICS, cont’d
• In theory:
• It forms a scaffold upon which endothelial regrowth can
occur, leading to the full coverage of the implant and the
aneurysm neck.
• When compared with selfexpanding or balloonexpandable stents, the PED has higher metal surface area
coverage, which greatly facilitates the occlusion of the
aneurysm neck and neointimal regrowth.
• In reality:
• True effect on neointimal remodeling is unknown.
Leung, G.K. et al. Pipeline Embolization Device for Intracranial Aneurysm: A Systematic
Review. Clinical Neuroradiology, 20012; 22: 295-303
37
Numa Perez, MSIII
Gillian Lieberman, MD
PED: EFFICACY
• Systematic literature review published in 2012
yielded:
• 414 patients with 448 intracranial aneurysms (IA)
• 78.3% were saccular or blister-like
• 83.5% of IAs were in the anterior circulation, 16.5% in the
posterior one
• Mean size was 12 mm (largest being 18.2 mm)
• Mean number of PEDs per IA was 2.0
• Deployment was successful in ~95% of procedures
• Obliteration was achieved in 82.9%
Leung, G.K. et al. Pipeline Embolization Device for Intracranial Aneurysm: A Systematic
Review. Clinical Neuroradiology, 20012; 22: 295-303
38
Numa Perez, MSIII
Gillian Lieberman, MD
PED: SAFETY
• Periprocedural intracranial vascular complication
rate: 6.3%
• Mortality rate: 1.5%
• Complications:
•
•
•
•
•
•
TIAs
SAH
ICH
Worsening of mass effect
IA rupture
Emboli
Leung, G.K. et al. Pipeline Embolization Device for Intracranial Aneurysm: A Systematic
Review. Clinical Neuroradiology, 20012; 22: 295-303
39
Numa Perez, MSIII
Gillian Lieberman, MD
ISA: MANAGEMENT PRIOR TO
RUPTURE, GUIDELINES
• Given the apparent low risk of hemorrhage from
incidental, small (<7 mm) aneurysms in patients without
previous SAH, observation rather than intervention is
generally advocated. However, special consideration
for treatment should be given to young (<50 years)
patients in this group.
• Asymptomatic aneurysms ≥7 to 10 mm in diameter
warrant strong consideration for treatment, taking into
account patient age, existing medical and neurologic
conditions, and relative risks for treatment.
Bederson, J.B. et al. Recommendations for the management of patients with unruptured intracranial aneurysms: A statement for
healthcare professionals from the Stroke Council of the American Heart Association. Circulation, 2000; 102(18): 2300-2.08
40
Numa Perez, MSIII
Gillian Lieberman, MD
BACK TO ISAs: COMPLICATIONS
• Most dreaded complication of ISA…
Rupture leading to Subarachnoid Hemorrhage (SAH)
41
Numa Perez, MSIII
Gillian Lieberman, MD
SAH
• Outcomes:
•
•
•
•
Overall case fatality 51%1
10% die prior to reaching Hospital
25% die within 24h
45% die within 30 days 2
• ~30,000 persons/year affected in North America
1.
2.
Broderick, J.P. et al. Initial and recurrent bleeding are the major causes of death following subarachnoid hemorrhage. Stroke, 1994; 25(7): 1342-1347
Hop, J.W. et al. Case-fatality rates and functional outcome after subarachnoid hemorrhage: a systematic review. Stroke, 1997; 28(3); 660 - 664
42
Numa Perez, MSIII
Gillian Lieberman, MD
SAH: CLINICAL MANIFESTATIONS
• Headache
1. Onset headache (“worst headache of my life”,
“thunderclap headache”)
• 19-25% of “worst headaches of my life” have SAH 1,2
• 30% of cases it lateralizes to side aneurysm.
• +/- brief loss of consciousness, seizure, nausea or vomiting, and
meningismus
2. Sentinel headache (“warning leak”) 3
• 10-43% of cases
• Precedes SAH by 6-20 days
1.
2.
3.
Linn, F.H. et al. Prospective study of sentinel headache in aneurysmal subarachnoid haemorrhage. Lancet, 1994; 344(8922):590-593
Morgenstern, L.B. et al. Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid
analysis. Annals of Emergency Medicine, 1998; 32: 297-304
Polmear, A. Sentinel headaches in aneurysmal subarachnoid haemorrhage: what is the true incidence? A systematic review. Cephalalgia,
2003; 23(10): 935-41
43
Numa Perez, MSIII
Gillian Lieberman, MD
SAH: DIAGNOSIS
• NCHCT
• 100% sensitivity and specificity within the first 6 hours *
• Lumbar puncture
• Mandatory if high suspicion but normal CT
• MRI
• FLAIR + T2 useful subacutely (>4 days)
* Perry J.J. et al. Sensitivity of computed tomography performed within six hours of onset of headache
for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ, 2011; 343:d4277
44
Numa Perez, MSIII
Gillian Lieberman, MD
SAH: COMPLICATIONS
1. Vasospasm
•
•
•
•
LEADING CAUSE OF DEATH & DISABILITY AFTER SAH
20-30% of cases
Usually no earlier than day 3
Results from spasmogenic substances released during lysis
of subarachnoid blood clots
2. Rebleeding
• 6.9-8.6% of cases
• Highest risk during first 24 h
3. Hydrocephalus
• 15% of cases
4. Increased ICP
• 54% of cases
45
Numa Perez, MSIII
Gillian Lieberman, MD
SAH: MANAGEMENT
1. Admission to ICU
2. DC anticoagulation if present
3. Vasospasm
1. TCDUS to monitor
2. Nimodipine to prevent poor outcome *
3. Angioplasty to treat
4. +/- Seizure Prophylaxis
5. Monitor ICP
1. Balance between risk of ischemia and rebleeding
6. Most importantly, treat aneurysm!!
* Barker F.G. et al. Efficacy of prophylactic nimodipine for delayed ischemic deficit after
subarachnoid hemorrhage: a metaanalysis. Journal of Neurosurgery, 1996; 84(3): 405-414
46
Numa Perez, MSIII
Gillian Lieberman, MD
BACK TO OUR PATIENT: MANAGEMENT
1. Admitted to ICU
2. Medical:
1. Nimodipine (to prevent poor outcomes related to vasospasm)
2. Levetiracetam (seizure prophylaxis)
3. External Ventricular Drain placed on immediate
arrival to ED (to monitor and maintain ICP)
http://www.uptodate.com/contents/image?imageKey=NEURO/56391&topicKey=NEURO
%2F1116&source=outline_link&search=external+ventricular+drain&utdPopup=true
47
Numa Perez, MSIII
Gillian Lieberman, MD
BACK TO OUR PATIENT:
MANAGEMENT, cont’d
4. Treated aneurysm endovascularly:
1. Coil embolization
2. PED placement
48
Numa Perez, MSIII
Gillian Lieberman, MD
BACK TO OUR
PATIENT:
MANAGEMENT,
cont’d
s/p Coil embolization
BIDMC PACS
49
Numa Perez, MSIII
Gillian Lieberman, MD
BACK TO OUR PATIENT:
COMPLICATIONS
1. Experienced increased ICP requiring right
hemicraniectomy.
2. Daily TCDUS showed signs of vasospasm in two
separate occasions requiring angioplasty.
3. Ventilator-acquired pneumonia requiring antibiotic
treatment.
50
Numa Perez, MSIII
Gillian Lieberman, MD
BACK TO OUR PATIENT:
OUTCOME
• Neurosurgery f/u 4 months after event
•
•
•
•
•
•
Alert and oriented x 3
Attention and concentration appropriate
No memory deficit noted
Appropriate language and fund of knowledge
Cranial nerves intact
Gait and coordination normal
51
Numa Perez, MSIII
Gillian Lieberman, MD
TAKE HOME POINTS
1. A great majority of ISAs arise around the Circle of
Willis.
2. Three approaches for management of ISAs,
analysis of the risks and benefits of asymptomatic
intervention is important.
3. Flow diversion is a novel approach to
endovascular management of ISAs that so far
displays better results and decreased rates of
complications in comparison to other
conventional surgical and endovascular
approaches.
52
Numa Perez, MSIII
Gillian Lieberman, MD
TAKE HOME POINTS, cont’d
4. Most dreaded complication of ISAs is rupture
leading to SAH -> ~50% mortality rate
5. 19-25% of patients c/o the “worst headache of my
life” have a SAH.
6. If SAH is suspected, performe NCHCT stat.
7. Vasospasm is the leading cause of death &
disability after SAH, prevent poor outcomes with
Nimodipine.
53
Numa Perez, MSIII
Gillian Lieberman, MD
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
http://www.uptodate.com
http://emedicine.medscape.com/
Vlak M.H. et al. Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country, and time period: a systematic review
and meta-analysis. Lancet Neurology, 2011; 10: 626-636
Brisman J.L. et al. (2012, July). Neurosurgery for Cerebral Aneurysm. Medscape. Retrieved from http://emedicine.medscape.com/article/252142-overview
Ronkainen A. et al. Familial intracranial aneurysms. Lancet, 1997; 349(9040): 380-384
Wiebers D.O. et al. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet, 2003;
362(9378):103
Wiebers D.O. et al. Pathogenesis, Natural History, and Treatment of Unruptured Intracranial Aneurysms. Mayo Clinic Proceedings, 2004; 79[12]: 1572-1583
Yi, M.H. et al. Contrast-free MRA at 3.0 T for the detection of intracranial aneurysms. Neurology, 2011; 77(7): 667-676
Menke, J. et al. Diagnosing cerebral aneurysms by computed tomographic angiography: meta-analysis. Annals of Neurology, 2011; 69: 646-654
Ferrel, A.S. et al. Developments on the horizon in the treatment of neurovascular problems. Surgical Neurology International, 2013; 4:s31-7
Kallmes, D.F. et al. A New Endoluminal, Flow-Disrupting Device for Treatment of Saccular Aneurysms. Stroke, 2007; 38: 2346-2352
Leung, G.K. et al. Pipeline Embolization Device for Intracranial Aneurysm: A Systematic Review. Clinical Neuroradiology, 2012; 22: 295-303
Bederson, J.B. et al. Recommendations for the management of patients with unruptured intracranial aneurysms: A statement for healthcare professionals
from the Stroke Council of the American Heart Association. Circulation, 2000; 102(18): 2300-2.08
Broderick, J.P. et al. Initial and recurrent bleeding are the major causes of death following subarachnoid hemorrhage. Stroke, 1994; 25(7): 1342-1347
Hop, J.W. et al. Case-fatality rates and functional outcome after subarachnoid hemorrhage: a systematic review. Stroke, 1997; 28(3); 660 – 664
Linn, F.H. et al. Prospective study of sentinel headache in aneurysmal subarachnoid haemorrhage. Lancet, 1994; 344(8922):590-593
Morgenstern, L.B. et al. Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid analysis. Annals of
Emergency Medicine, 1998; 32: 297-304
Polmear, A. Sentinel headaches in aneurysmal subarachnoid haemorrhage: what is the true incidence? A systematic review. Cephalalgia, 2003; 23(10): 93541
Perry J.J. et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage:
prospective cohort study. BMJ, 2011; 343:d4277
Barker F.G. et al. Efficacy of prophylactic nimodipine for delayed ischemic deficit after subarachnoid hemorrhage: a metaanalysis. Journal of Neurosurgery,
1996; 84(3): 405-414
54
Numa Perez, MSIII
Gillian Lieberman, MD
ACKNOWLEDGEMENTS
Thanks to,
Ms. Claire Odom, for all the hard work that goes into
organizing our clerkship and for always supporting us
when we need your help.
Dr. David Khatami, for bringing this great case to my
attention and for helping me navigate all the
radiological findings.
Dr. Gillian Lieberman, for putting your heart and soul
into our clerkship and for providing us with a radiology
experience worthy of envy, one which will certainly
contribute to us becoming better physicians in the
near future.
55
Numa Perez, MSIII
Gillian Lieberman, MD